State Tobacco Control Program Spending — United States, 2011

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable reduce smoking rates and tobacco-related diseases and deaths. States that made larger investments in tobacco prevention and control have seen larger declines in cigarettes sales than the United States as a whole, and the prevalence of smoking has declined faster as spending for tobacco control programs has increased. CDC's Best Practices for Comprehensive Tobacco Control Programs (Best Practices) outlines the elements of an evidence-based state tobacco control program and provides recommended state funding levels to substantially reduce tobacco-related disease, disability, and death. To analyze states' spending in relation to program components outlined within Best Practices, CDC assessed state tobacco control programs' expenditures for fiscal year 2011. In 2011, states spent approximately $658 million on tobacco control and prevention, which accounts for less than 3% of the states' revenues from the sale of tobacco products and only 17.8% of the level recommended by CDC. Evidence suggests that funding tobacco prevention and control efforts at the levels recommended in Best Practices could achieve larger and more rapid reductions in tobacco use and associated morbidity and mortality.

Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable reduce smoking rates and tobacco-related diseases and deaths (1,2). States that made larger investments in tobacco prevention and control have seen larger declines in cigarettes sales than the United States as a whole (3), and the prevalence of smoking has declined faster as spending for tobacco control programs has increased (4,5). CDC's Best Practices for Comprehensive Tobacco Control Programs (Best Practices) outlines the elements of an evidence-based state tobacco control program and provides recommended state funding levels to substantially reduce tobacco-related disease, disability, and death (1,2). To analyze states' spending in relation to program components outlined within Best Practices, CDC assessed state tobacco control programs' expenditures for fiscal year 2011. In 2011, states spent approximately $658 million on tobacco control and prevention, which accounts for less than 3% of the states' revenues from the sale of tobacco products and only 17.8% of the level recommended by CDC.* Evidence suggests that funding tobacco prevention and control efforts at the levels recommended in Best Practices could achieve larger and more rapid reductions in tobacco use and associated morbidity and mortality (2,3).
Following CDC's first publication of Best Practices in 1999, overall funding for state tobacco control programs has more than doubled, and states restructured their tobacco control programs to align with CDC's goals and programmatic recommendations (2). The 1999 report recommended that states invest a combined $1.6 to $4.2 billion annually in such programs. In 2007, the recommendation was updated to $3.7 billion annually (1). These recommendations were updated again in 2014 ($3.3 billion) to reflect additional state experiences in implementing comprehensive tobacco control programs, new scientific literature, and changes in state populations, inflation, media costs, Affordable Care Act effects, and the national tobacco control landscape (2). To date, all 50 states and the District of Columbia (DC) have state tobacco control programs that are funded through various revenue streams, including tobacco industry master settlement payments to states, cigarette excise tax revenues, state general funds, federal government funds, and nonprofit organizations. † For this analysis, researchers from the Health Policy Center at the University of Illinois at Chicago obtained reports of state tobacco control programs' expenditures for fiscal year 2011 for all 50 states and DC. They directly contacted representatives within relevant state organizations and agencies, and accessed their websites. § When multiple agencies and organizations were responsible for a state's tobacco control program, expenditures from each organization were combined. In addition to total tobacco control expenditures, expenditure data were collected for the five program components outlined in Best Practices (2007)

Discussion
The findings in this report reveal that state investments in tobacco prevention and control programs in fiscal year 2011 were considerably less than levels recommended in CDC's Best Practices (1,2). In 2011, states spent only $658 million (<3% of $24.2 billion they received from tobacco tax revenues and Master Settlement Agreement payments*) in tobacco control and prevention activities, compared with the $8.8 billion that tobacco companies spent on cigarette and smokeless tobacco advertising and promotion that year (6,7). Despite significant declines in cigarette smoking in recent years, 17.8% of U.S. adults and 15.7% of high school students still smoke cigarettes (8,9). Moreover, the prevalence of use of other tobacco products such as cigars and smokeless tobacco has not changed (3), and the prevalence of use of emerging products, including electronic cigarettes (e-cigarettes) and hookah, has rapidly increased (3). Investing in comprehensive tobacco control programs and implementing evidence-based interventions have been shown to reduce youth initiation, tobacco-related disease and death, and tobacco-related health care costs and lost productivity. Moreover, if states allocate funding for tobacco control at CDC's Best Practices levels, they have the potential to achieve larger and more sustainable reductions in all forms of tobacco use and associated morbidity and mortality (2,3).
These findings demonstrate a considerable gap between state investments in tobacco prevention and control and CDC's Best Practices recommendations. Although all states derive revenues from cigarette excise taxes, few states have a statutory requirement requiring that a portion of these revenues be dedicated to tobacco prevention and control (10). Instead, most cigarette tax revenues are used for general purposes. Additionally, although in recent years state cigarette excise taxes have nationally increased, these tax increases largely have come in response to shortfalls in state budgets, rather than as initiatives to increase tobacco control spending (1,2). Many state programs have experienced and are facing substantial state government cuts to tobacco control funding, resulting in the near-elimination of tobacco control programs in those states (2). In 2014, despite combined revenue of more than $25 billion from settlement payments and tobacco taxes for all states, states have appropriated only $481.2 million (1.9%) † † to comprehensive tobacco control programs, an amount <15% of the CDC-recommended level of funding for all states combined (2). Only two states, Alaska and North Dakota, currently fund tobacco control programs at CDC-recommended levels. § § Implementing comprehensive tobacco control programs at CDC-recommended levels could have a substantial impact: millions fewer persons in the United States would smoke and hundreds of thousands of premature tobacco-related deaths could be prevented; long-term investments could have even greater effects (2,3).
The findings in this report are subject to at least three limitations. First, some expenditure data might not have been captured because it was spent by agencies or organizations that were not tracked, which could result in underestimation. For example, direct service expenditures on cessation by private insurers were not captured, neither were the direct expenditures on cessation made by state Medicaid in most states. However, aggregated state tobacco control expenditures were comparable with state tobacco control funding data reported elsewhere (10). Second, expenditure data were self-reported. As a result, variations might exist with regard to expenditure classifications across states. Finally, private organizations or foundations using private funds to conduct tobacco prevention and control activities were not included in the reported expenditures, which would lead to underestimation.

Summary
What is already known on this topic?
Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable reduce smoking rates and tobacco-related diseases and deaths. States that made larger investments in tobacco prevention and control saw larger declines in cigarettes sales than the United States as a whole. The prevalence of smoking has declined faster as spending for tobacco control programs has increased.
What is added by this report?
In What are the implications for public health practice?
State investments in tobacco prevention and control programs in fiscal year 2011 were considerably less than levels recommended in CDC's Best Practices. Full implementation of comprehensive tobacco control policies and evidence-based interventions at CDC-recommended funding levels could result in a substantial reduction in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs and lost productivity in the United States.
smokeless tobacco (6,7). During the same period, more than 3,200 youth younger than 18 years of age smoked their first cigarette and another 2,100 youth and young adults who are occasional smokers progressed to become daily smokers (3). If current rates continue, 5.6 million Americans younger than 18 years of age who are alive today are projected to die prematurely from smoking-related disease (3). However, the tobacco-use epidemic can be markedly reduced by implementing interventions that are known to work. Full implementation of comprehensive tobacco control policies and evidence-based interventions at CDC-recommended funding levels could result in a substantial reduction in tobacco-related morbidity and mortality and billions of dollars in savings from averted medical costs and lost productivity in the United States (2,3).